First – Do No Harm

The aphorism has been directed at generations of doctors and medical students. It may be hackneyed, but it has never lost its relevance. For the potential for doctors actually to harm rather than heal their patients is always there and always will be. Harm may come about as a consequence of omission (negligence or inadequate skills and knowledge) or over-enthusiastic, if well intended, intervention.

I often told my patients who were eager that “something must be done” that, while I acknowledged the discomfort or pain that their predicament was causing them, my first priority had to be that of their safety. Powerful medicine may have powerful – indeed sometimes lethal – side effects. Particularly so if the patient is very young or very old.

Not long ago a gentleman in his 80s came to see me. I was working as a locum – “helping out” on a one off basis at a surgery where one of the doctors had been taken ill. I invited him to tell me why it was he had come to see me. He did so at some length. He has seen both regular doctors in the practice and had been referred to hospital where he had had tests including scans to determine the cause of his abdominal bloating. He was on several medications including a pretty fierce laxative. My own view was that therein lay his problem. I noted that he emphasised that he had been told that there was “nothing wrong” with him but that he was unable to accept that to be the case. My own assessment was that his symptoms related to chronic constipation and were very probably compounded by the medications he was taking, and, of course, his age. But he expressed the view that no doctors had been of any help to him at all.

I expressed my concern and sympathy and assured him that I never tell a patient that there is “nothing wrong with you” (not least because there has to be something wrong with all of us, imperfection being the nature of the human organism). I then tried, tactfully and at length, to put across the ill-advisedness of what we, in the profession, call “doctor hopping”. This has the potential to be the most dangerous thing a frustrated patient can do. Some hold on to a common misconception that a “new” doctor can through a new light on to their symptoms. Sadly, this is rarely the case.

I went through his records and assured him that the opinions and investigations he had been given did not demonstrate the likelihood of any serious illness. I then went on to attempt to put across the fact that my first concern was that of “doing no harm”, something that might very well be the result were I to “try another treatment” or referring him for yet more tests.

I must have got it wrong. For he misconstrued my honest and genuine concern as dismissiveness and lack of interest. He threw the classical barb at me “so you’re not going to help me, doctor?” He then went on to make a personal comment about me that was actually quite rude. No matter. 40 years in the job mean that I am little hurt by these things.

It may be that I will be slandered in the pub or post office queue. I will take that in good heart as there is nothing I can do about it. But you may be very sure that I wrote a detailed and accurate account of the consultation and what I said to him in his records. For I have no doubt that when he returns to see his “regular” GP he will have things to say about the useless doctor they’d employed in his absence. And I am less tolerant of slander delivered about me to medical colleagues.

A Particularly Nasty Scam

A friend was telling me recently of yet another scheme devised by the unscrupulous to get money out of vulnerable people. It seems that these characters are taking note of small high street shops that happen to be playing music on the radio, and then sending official looking letters to the shopkeeper saying that they are in breech of the law, that they are being fined and that they should post a cheque to such and such an address. My friend had this related to her by the owner of a shop she used regularly, and he was clearly frightened and uncertain what he should do. Friend checked with her son, who is a solicitor, and he immediately sussed out what was going on. He took a copy of the letter and is acting on it, much to the relief of the unfortunate shopkeeper.

It's difficult to understand the mind set of people who deliberately target vulnerable, frail or isolated people and think them fair game.

Like many of you, I myself get emails from people who offer to relieve me of my money on one pretext or another. Most recently from an "organisation" purporting to be HM Revenue and Customs saying I was entitled to a tax rebate and would I kindly supply bank details. I didn't, of course, and deleted the email. But how many people <I>do</I> fall for these things?

Dancing – one of the best antidepressants?

My wife was always a “natural” when it came to dancing, and it has been one of my few disappointments in all the years we’ve been married that, for all the evening classes we’ve gone to, I never got anywhere near her standard. Certainly not good enough to do her credit on the dance floor. She never complained, mind, but I knew she was a bit sad about it.

            Well, having not long been retired I thought I would give it one last go, this time of a 4 day residential course in Ballroom and Latin at a hotel and leisure complex in Torquay. This meant lessons every day and social dancing with our fellow students in the evening.

            Our dance tutors – a married couple who had been teaching dance for years – were excellent. Also encouraging. And for the first time I found that among my fellow learners were a few who were, well, even worse than I was. I did admire them of persevering and indeed they did make progress.

            But perhaps not as much as I did. With the excellent tuition and help I really felt myself getting somewhere at last. By the end I was dancing competently enough with my wife the cha-cha-cha, waltz, social foxtrot and quickstep. She was thrilled. And of course we are going to go forward from here.

            And I had an interesting conversation with one participant who, on hearing that I had been a doctor, told me that on this course she had just stopped taking the fluoxetine (Prozac) she’d been prescribed for years and hadn’t felt so good for a long time.

            On reflection I wondered whether this had to do with four effects that dancing has:

1. It is excellent exercise. And safe. We both wear step counters and aim to clock up 10,000 steps a day to keep in trim. On the course we were at or above 20,000 steps.
2. Done well it has an elegance and beauty.
3. The music is wonderful.
4. People tended to get dressed up in a way that has largely gone out of fashion. The women, young and old, took a lot of trouble and pretty well without exception looked fantastic. The men wore smart casual, and about half (myself included) wore jacket and tie (no-one went so far as tails, mind). Making yourself look good makes you feel good.

We came home refreshed and elated. I can only recommend it.

Impermanence and the Persistence of Memory

In the late summer of 1980 my wife and I were on holiday with our three children, then aged 10, 8 and 7. We stayed with my wife’s widowed mother at her small farm in County Mayo in the west of Ireland.

            We had a spell of good weather, and for a few days the children and I got into the way of going down to the river that marked one of the boundaries of the farm. The water was low and it flowed gently as the stream meandered through the meadows. We gathered pebbles and larger stones and built castles in the shallow water. Fairy castles, goblin castles, castles for kings and queens and whatever. My wife and her mother came down to see what we were doing on the last fine evening before we returned to life and work in London.

            Christmas was approaching and my wife telephoned her mother to talk as they often did. Her mother told her, with a note of sadness in her voice, that after we had left with her grandchildren a few months previously that she had from time to time walked of an evening to the stream. ‘It was so lovely to see their little castles and to remember the children. But then we had a few days of heavy rain. The water rose and all the little castles were washed away’.

            Last weekend we had two of our grand-daughters come to stay with us. They are cousins, now aged 7 and 5. They don’t see each other very often as they live over two hundred miles apart. They get on very well together, the younger child, Imogen, being quite advanced and confident for her age. And so they had a grand time together, which included an outing with their grandma and grandpa to the Egg Theatre in Bath to see one of their lovely children’s productions.

            It was unusually fine weather on the Saturday afternoon, and the two girls were out in the garden. Kitty came in and asked “Grandma – can we pick some flowers please? We want to make a flower shop.’ It was getting towards the time when the garden was to be put to sleep for the winter and so yes, of course they could pick flowers.

            Within an hour they had adorned the garden seat with little bunches of geraniums and nasturtiums, each with its card showing the price. We took photos of them. Our hearts melted.

            The weather changed after they had left us, one to Taunton and the other to Chelmsford. My wife and I had not the heart of course to tidy away their little shop, and felt a sweet sorrow when the wind and rain scattered the little bouquets and cards as they must surely do.

            ‘Do you remember that autumn with your mother, when the children built their castles in the stream?’ I asked my wife.

            ‘I was just thinking of that’ she said quietly, and took my hand and held it tightly.

            We both of us were thinking how time can go by in an instant, while memories may never decay. When another 30 or so years have gone by, where, we wonder, might these little ones be placing their flowers then?

Medical Stereotyping and Misinformation

Not long ago I read a blog entry that referred to doctors (general practitioners) habitually greeting their patients with "And what can I do for you today?" while at the same time reaching for the prescription pad.

            I began to wonder how such stereotypes originate, and how they persist in people's perception when common experience has to be that this sort of cameo is anything but commonplace in the real world. Perhaps it never was. Or maybe it is a creation of medical "soaps". I wouldn't know - I never watch them.

            Doctors are not quite the fools that this image might suggest that they are. For the notion that they can help at all in a fair proportion of cases presenting to them is a false one. "Help" implies an intervention of some sort or another, and this is usually unwise unless one knows exactly what the issue is that one is dealing with, and with a clear objective in mind. What doctors really do of course is to try to make sense with the patient just what is going on that caused the patient to come (so best to start along the lines of "so please tell me what it is you have come to see me about today"). They will try to identify reasons why the situation has arisen or might have arisen, to suggest what might be the outcome if left to itself, and finally to consider what, if any means might be utilised to modify the outcome. This last is the "help" if you like. And the wise doctor who sticks by the aphorism "first do no harm" will be circumspect on the subject of, say, ordering tests and, yes, putting pen to the prescription.

            "Advice" is another two edged sword in the doctors repertoire of interventions. It should not be given incautiously, particularly if it is the "if I were you" sort of advice. Because the doctor is not the patient. Only the patient can decide, in the end, how to address their problem. The best a doctor can do is to put the patient in a position to make the choice that is best suited to her or him out of perhaps several choices (for example: to take medicine/not to take medicine; to embark on a series of tests/adopt a "wait and watch" approach).

            Those situations where a reason (diagnosis) can be established unequivocally may indeed have limited or no choices of management for a safe and effective outcome are actually not that common. But your everyday coughs, colds, backache, piles, anxiety states and sadness will by and large get better by themselves - and so the patient must be given the option of allowing a natural recovery to occur in its own time. All of them, of course, are amenable to interventions that may be more or less effective. And all interventions have the potential to cause adverse effects, a few of which may leave the patient worse of than he was. Or dead.

The Italian Courts this week

I am quite taken aback by the headlines splashed across so many of the national newspapers this week, and the detailed account of the successful appeal by the young woman accused of the murder of Meredith Kercher. I have not read these in any depth, being curious only about the part that the Italian courts have played, particularly with regard to the way in which the original verdict was reached. Justice seems to be an elusive commodity.

The details and speculation about the original crime itself I find distasteful. I have had to deal with violence and its consequences too often in my professional career to get any kick of reading accounts such as have been published. But clearly there is money to be made out of writing about such infamy and depravity. We are told that the winner of the appeal is set to become wealthy by selling her story.

So people clearly do want to read this material. And I am left wondering just what sort of people they are who have such tastes in “literature”. To what depths of degradation are we descending, I wonder.